An amended version of Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies with an effective date of Feb. 1, 2023, was posted to the NC Medicaid Clinical Coverage Policy web page.
Summary of Updates
In Subsection 5.3.6 Nutrition, the following medical necessity criteria for in-line digestive enzyme cartridges were added:
In-line Digestive Enzyme Cartridges
In-line digestive enzyme cartridges, such as Relizorb, may be considered medically necessary when all the following criteria are met:
a. Beneficiary is at least five years of age;
b. Beneficiary has a diagnosis of exocrine pancreatic insufficiency (EPI); and
c. Beneficiary meets the criteria for enteral nutrition as documented in this policy.
Note: If the above medical necessity criteria are met, then prior authorization is not required.
New Subsection 5.3.10 Electric Breast Pumps with the following medical necessity criteria was added:
Electric Breast Pumps
Refer to Attachment A, Section C: Procedure Code(s) for a list of HCPCS codes, established lifetime expectancies and quantity limitations for Durable Medical Equipment and Medical Supplies. To request a medical necessity review for an item not listed, refer to Subsections 1.2, 2.2 and Attachment D for instructions.
A breast pump is a device used to extract milk from the breast of a lactating mother for infant feeding when the mother cannot be present at feeding time or when the infant is too sick or too weak to suckle.
An electric breast pump requires prior authorization and is considered medically necessary when one of the following criteria is met:
a. During the time when a newborn is detained in the hospital after the mother is discharged; or
b. The newborn has a congenital anomaly that interferes with feeding (such as cleft palate, neuromuscular disease or congenital heart defect); or
c. A medical condition that causes low milk production is present (such as prematurity, thyroid conditions, polycystic ovarian syndrome, diabetes, or obesity).
Note: If a rental hospital grade breast pump is medically necessary, then the PA may be limited to one month at a time.
In Attachment A: Claims-Related Information, Section B: International Classification of Diseases and Related Health Problems, Tenth Revisions, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS), Diagnosis Code K86.81 (exocrine pancreatic insufficiency) was added as an acceptable diagnosis for in-line digestive enzyme cartridges.
In Attachment A: Claims-Related Information, Section C: Procedure Code(s), the following updates were made:
Quantity limits were updated for existing HCPCS codes:
| HCPCS code | Description | Unit limit prior to 2/1/2023 | Unit limit on and after 2/1/2023 |
|---|---|---|---|
| A4371 | Ostomy skin barrier, powder, per oz. | 2 oz. per month | 10 oz. per month |
| A5056 | Ostomy pouch, drainable, with extended wear barrier attached, with filter, (one piece), each | 20 per month | 40 per month |
| A5057 | Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (one piece), each | 20 per month | 40 per month |
Coverage and Quantity Limits Added for HCPCS Codes
A4238 (supply allowance for adjunctive continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service),
A4281 (tubing for breast pump, replacement),
A4282 (adapter for breast pump, replacement),
A4283 (cap for breast pump bottle, replacement),
A4284 (breast shield and splash protector for use with breast pump, replacement),
A4285 (polycarbonate bottle for use with breast pump, replacement),
A4286 (locking ring for breast pump, replacement),
A4315 (insertion tray with drainage bag with indwelling catheter, foley type, two-way, all silicone), A4434 (ostomy pouch, urinary: for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each),
A5081 (stoma plug or seal, any type),
A5082 (continent device; catheter for continent stoma),
A5083 (continent device, stoma absorptive cover for continent stoma),
A5112 (urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each),
B4105 (in-line cartridge containing digestive enzyme(s) for enteral feeding, each),
E0603 (breast pump, electric (AC and/or DC), any type),
E0604 (breast pump, hospital grade, electric (AC and/or DC), any type),
E2102 (adjunctive continuous glucose monitor or receiver) and
K1005 (disposable collection and storage bag for breast milk, any size, any type, each).
The descriptions for covered HCPCS codes A9276, A9277 and A9278 were updated in compliance with the CMS HCPCS code annual update.
In Attachment A: Claims-Related Information, Section F: Place of Service, was updated for clarity:
Place of Service
12-Home, 04-homeless shelter, 13-assisted living facility, 14-group home, 33-custodial care facility, 34-hospice
Additional Resources
The DME fee schedule and full text of Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies is available at North Carolina Medicaid’s Durable Medical Equipment (DME) web page.
Contact
NC Medicaid Contact Center, 888-245-0179